The Transparency Revolution
There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.
Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.
Jim Conway at the Institute for Healthcare Improvement recently said this succinctly. By opening themselves up to public scrutiny, providers will "have the courage to be held accountable in the name of the patients coming to our hospitals, as well as to our own staff. Shining light on an organization drives improvement."
People who have studied process improvement in other service and industrial sectors have known this for years. The push for transparency has driven changes in fields as diverse as computers and chemical refineries. In those fields, the impetus was a desire to gain market share in the face of a rising tide of quality expectations from corporate customers. Decades ago, Bose wanted to sell its loudspeakers to Japanese car manufacturers, and it had to document to those companies that its equipment would meet the high expectations of Toyota (TM) and Honda (HMC). Likewise, Intel (INTC) had high expectations to meet if its processors were to find their way into a multitude of computers, from IBM (IBM) to Dell (DELL).
In health care, there appears to be a different driving force for transparency. We don't see just a few major suppliers selling to relatively major customers, as happens elsewhere in the corporate world. Instead, there are thousands of providers offering service to millions of patients, thousands of corporate employers, and hundreds of insurance companies. Notwithstanding the dispersion of this group of providers and consumers, momentum for transparency is growing. For the insurers and the employers, it is probably driven by cost concerns and an underlying belief that the rate of health cost increases can be trimmed if the quality of care is enhanced. For the patients, there has been a widespread growth in a more informed consumer economy in a variety of other fields. People now have expectations of being able to find data on the quality of products and service on the Internet.
"Wave of Accountability"
But as Conway notes: "The wave of accountability is moving more quickly than the speed of the industry in adapting to it." Why is this? I've had a chance to study the sociology of health-care institutions in Boston over the past few months on this topic. Several months ago, I started to post infection rates and other clinical information about Beth Israel Deaconess Medical Center (BIDMC) on my blog. I suggested, too, that it would be great if other hospitals in Boston would do the same thing. Not for competitive purposes, but to show the public that we were all willing to be held accountable and to demonstrate our commitments to quality improvement.
The response was either underwhelming or hostile. I received arguments against the idea because "the data wouldn't be comparable from one hospital to the next," and "the public won't understand it." I was accused of seeking competitive advantage. I never understood that one, in that I had no idea if our numbers were better or worse than the competition. (One chief executive actually said that he would post their numbers only when they were good and ready, but that their numbers were better than ours!)
I suggested that if we didn't do this ourselves, it would someday be mandated for the industry by legislators or regulators, and then we would have a great deal less say in how and which numbers would be presented.
The sociological issue is this: Doctors are incredibly dedicated people who devote their lives to alleviating human suffering. They have to believe that the care they are giving patients is very good. How else could you live with yourself after all that training and clinical experience? They are also scientists who are expert at judging whether data presents an accurate representation of biological processes. So here we are proposing to post admittedly imperfect data about admittedly imperfect clinical results. It really rubs them the wrong way.
At BIDMC and several other hospitals in the country, there is an acknowledgement and understanding that the posting of clinical results for the public to see is not a statement of blame or criticism. It is actually a source of pride to our doctors and nurses in that it reaffirms to the public that we are trying our best to get better and better at what we do. We have a fundamental trust that the public will view these figures with understanding and tolerance because they know that we are acting in their interest. The task for other hospitals in the country is to get onto this bandwagon and enjoy the benefits that can come from this kind of disclosure.